AUCTORES
Globalize your Research
Research Article | DOI: https://doi.org/10.31579/2692-9406/030
*Corresponding Author: Raphael Staubach, M.D, Klinikum Stuttgart/ Olga hospital, Department of Pediatric Surgery, Kriegsbergstraße 60/62, 70174 Stuttgart, Germany, Phone: +49 711 278 55559.
Citation: R Staubach, Glosse H, Fennell S, Mehlig U. (2020) Full-thickness skin grafts (FTSG) with a new technique. Biomedical Research and Clinical Reviews. 1(5); DOI:10.31579/2692-9406/030
Copyright: © 2020 Raphael Staubach, This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 29 October 2020 | Accepted: 20 November 2020 | Published: 23 November 2020
Keywords: technical innovations; surgical procedure; full thickness skin grafts; reconstruction; burn
Introduction: Full-thickness skin grafts (FTSG) have long been an indispensable and frequently practiced standard procedure in plastic surgery. The defatting and thinning of the grafts with scissors or scalpel to a thickness of 0,8 – 1,2 mm is very time-consuming even for experienced surgeons in the case of large transplants. Devices for full-thickness skin graft defatting are not available on the market. For this reason, we developed a relatively simple device that enables complete and safe degreasing and thinning of the graft in the shortest possible time.
Materials and Methods: The machine has a dimension of 38cm width, 24cm length, 23cm height. The cutting thickness can be set to 0.6mm, 0.8mm, and 1.0mm. The central part is a crimper run manually with a crank to guide the specimen through a cutting blade. The machine is made of stainless steel, can be completely disassembled, and is easy to sterilize.
Results: With this device small and very large skin grafts up to 15 cm in width can get completely defatted within a few seconds.
Discussion: The time for defatting is reduced by many times. Precious operating time is spared. It can be assumed that the healing of the graft is improved due to a more complete defatting, a much shorter manipulating time of the skin and a more even cut surface compared to the manual procedure. The risk of defects in the graft and of injury of the surgeon is minimized compared to manual preparation.
Full-thickness skin grafts (FTSG) have long been an indispensable and frequently practiced standard procedure in plastic surgery. Important indications for a full-thickness skin transplant are primary coverage of deep skin defects after trauma or tumor excision and secondary plastic corrections of scars after deep 3rd and 4th-degree burns. Essential for proper healing of the FTSGs is the thinning of the skin to about 0.75- 1.2 mm so capillaries can grow from the wound bed into the graft [1, 2, 3, 4].
The need for thinning grafts is common for small transplants as well as for large grafts. Especially for large transplants, the removal of subcutaneous fat of the donor site is necessary for later low-tension wound closure. This subcutaneous fat then has to be removed before transplanting the skin. Until now the preparation of grafts in terms of thinning and defatting is performed with scalpels and scissors while stretched over a finger by surgeons themselves. Even for experienced surgeons, this involves a risk of damaging the graft or not preserving the exact thickness of the graft. This process is very time-consuming.
For this reason, we developed a relatively simple device that enables complete and safe defatting or thinning of the graft in the shortest possible time. The basis for this defatting unit are well-approved machines of the meat processing industry for debriding animal skins. In cooperation with skinner Mr. Dietmar Anti (MAJA / Kehl-Goldscheuer), we developed a device for defatting FTSGs within seconds to create an ideal graft.
In the period 2017-2020, a series of experiments were carried out on both animal and human skin. Starting in 2017 with preliminary tests on animal skin, we developed a first prototype of the machine. The prototype was then tested on human skin in 10 test cycles, using accumulated skin from plastic surgery interventions. Several modifications were necessary until its final version.
The machine (LOMA - “LOFF MAJA”) is made of stainless steel, can be disassembled into 10 numbered parts and meets the requirements for sterilization. The core of the LOMA is a crimper that is driven by a hand crank. The fat is separated by a sharp fixed blade. The cutting thickness can be adjusted in 3 heights: 0,6 mm, 0,8 mm, and 1 mm.
Process: The epidermal side of the graft to be defatted is placed on the carrier table and one corner of the graft is brought up to the crimper (A). By manually turning the crimper, the epidermal side of the graft is captured by the corrugation of the crimper and guided through the cutting edge (B). The process takes about 5 seconds. The result is a completely degreased graft, with more or less dermis, depending on the skin’s thickness and position (C).
Results
Preliminary tests with a professional skinning machine and piglet skin
A TEM (table skinning machine) was used as the machine. The electric drive was replaced by a hand crank attached to the gearbox. By manually turning the crimper, the machine can be operated with care. The experiment was performed by a butcher with fresh suckling pigskin, as this is thinner than the skin of older pigs and comparable to human skin. The donor site was in the area of the lower abdomen, as the skin is very soft there. The skin was removed together with subcutaneous fat in the form of a 120mm x 50mm skin spindle. The rind was manually guided to the blade. The epidermis was captured by turning the crimper, the graft then pulled through the blade. However, the epidermis showed superficial cuts due to the sharp-edged ribs of the roller. An initial prototype of the machine has now been designed to meet the following requirements for defatting Full-thickness skin grafts (FTSG) in the operating theatre: The device must be able to be operated manually. Possibility to defatting large full-thickness skin grafts (FTSG), e.g. from the lower abdomen with a size of 20 x 20 cm. The surface of the crimper must ensure a safe grasp of the epidermis without injuring it.
Experiments with the first functional model and piglet skin
After completion of the first functional model, experiments with fresh piglet skin were conducted. The graft was completely and evenly degreased. Three different crimpers had been produced, each with a different corrugation on the surface. It was found that completely rounded edges of the corrugation did not sufficiently capture the graft, while sharp edges injured the epidermis. The ideal condition of the crimper corrugation was determined during the tests. This corrugation with customized rounded edges was used in the future.
Experiments with the first functional model and human skin
The very large pieces of skin after abdominal wall plasty were cut with scissors in such a way that skin spindles were created typically for full-thickness skin grafts (FTSG) of any size. The skins were completely degreased. The impressions from the crimper on the epidermal side were unproblematic and disappeared completely after 2 days. Series were carried out with different settings of the knife holder, with identical, reproducible results. The grafts can be degreased to almost any size. The cut surface is completely even and completely degreased. The cut surface of the separated fat shows that whitish dermis remains can be seen on it, i.e. the depth of cut was in the area of the dermis. Corrections were made to the first prototype: It turned out that the resistance while turning the crank was too high, so a gear transmission was necessary.
Experiments with an improved second functional model and human skin
The second functional model has a cutting width of 20 cm. This can be used to degrease transplants of any length with a maximum width of 15 cm. According to the authors’ experience, this corresponds to the maximum size of removable full-thickness skin grafts (FTSG), e.g. in the lower abdomen from spina to spina. The crimper drive is equipped with a 2:1 ratio. This means that even wide transplants can be easily defatted by one person. The height of the frame has been optimized for comfortable use.
Experiments with an improved third functional model and human skin
The final device has a dimension of 38 cm width (without crank), 24 cm length, 23 cm height. The maximum cutting width is 20 cm (D-F). The crimper has a corrugation that is suitable for gripping the graft securely without damaging it. The impressions from the crimper on the epidermal side are unproblematic and disappeared completely after 2 days. In order to allow easy turning, the crank force was increased by a transmission (E). The cutting thickness can be set to 0.6 mm, 0.8 mm and 1.0 mm. According to our measurements, the transplants actually have a slightly greater thickness. This is exactly within the required range of 0.8-1.2 mm.
The precise defatting of FTSG is an essential condition for a proper growth-in of transplants by reducing the diffusion distance between the epidermis and the graft base. This important but simple work is carried out worldwide with scissors, whereby the graft is usually stretched over a finger. The procedure is time-consuming and requires a great deal of attention so that neither the surgeon’s finger is injured, nor defects are cut into the graft.
Devices for full-thickness skin grafts (FTSG) defatting are not available on the market. For this reason, we have developed the LOMA transplant defattener described above. These are the advantages of the new device:
The risk of defects in the graft is minimized compared to manual preparation. Manual defatting frequently leads to perforations of the preparation, especially in the production of very thin grafts. When defatting with the LOMA device, we were only able to provoke a defect in the graft if the subcutaneous fat was pulled too strong during the cutting process. This should therefore be avoided at all costs.
The risk of injury to the surgeon’s fingers is also minimized compared to manual defatting. If the sharp blade is handled properly - just like a dermatome blade - injury to the surgeon and operating staff should be ruled out.
The weight of the device can be mentioned as a disadvantage. The size resulted from the design, which was repeatedly modified by experiments. As the LOMA should perform as a wide-range defattener including preparations of large FTSGs, a smaller version was not practical
Conclusion
The defatting process with this new device is much faster than manual preparation and operating time is spared. Defatting becomes easier and more precise even without special surgical expertise. Moreover, the risks of defects and injury of the surgeon‘s fingers are minimized. Summarized the LOMA machine is a new invention to improve the process of a full skin graft transplantation.
Funding: None.
Conflicts of interest:
We have no conflict of interest to declare. Also there is no commercial interest in the device from all Authors. This statement is to certify that all Authors have seen and approved the manuscript being submitted. We warrant that the article is the Authors’ original work. We warrant that the article has not received prior publication and is not under consideration for publication elsewhere. On behalf of all Co-Authors, the corresponding Author shall bear full responsibility for the submission.
Ethical approval: Not required.
Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.
Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.
Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.
Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.
We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.
The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.
Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.
Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.
Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.
Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.
Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.
This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.
Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.
As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
